Patient With Sudden Onset of Intermittent Mid-Epigastric Pain

MP is a 55-year-old woman who presents with complaint of inability to hold urine. She describes incidents where laughing or coughing results in a small to moderate release of urine. She has started wearing Peri Pads to avoid embarrassment.

Past Medical History

• Six vaginal deliveries, all to full term

• Osteoarthritis

• Postmenopausal

Medications

• Boniva, 150 mg once a month

• Calcium, 500 mg daily

• Vitamin D3, one daily

Family History

• Mother, alive and well; hypertension, type 2 diabetes

• Father, deceased; cardiovascular disease, myocardial infarction at age 77

Social History

• No alcohol intake

• Previous smoker

• Walks 2 miles/day

Physical Examination

• Vital signs normal

• Palpation of uterus suggests enlargement

Labs

• Liver function: Normal

Discussion Questions

1. What factors in MP's history would help support a diagnosis of overactive bladder?
2. The clinician prescribes oxybutynin 10 mg (extended-release). What does MP need to know about this drug?
3. If oxybutynin is ineffective, the clinician could use mirabegron, a beta-3 agonist. What does MP need to know about this new drug?

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Patient With Sudden Onset of Intermittent Mid-Epigastric Pain

PR is a 35-year-old female who presents with a sudden onset of intermittent mid-epigastric pain that started 4 weeks ago. Pain is 6/10 on the pain scale and described as burning that worsens after she eats Mexican food and when she is lying down. She has never experienced this before. PR reports that she has been taking over the counter (OTC) antacids that seemed to help at first, but now they provide no relief. She reports associated regurgitation and feeling of fullness all the time and this morning she had a sore throat.

Past Medical History

• Anaphylactic reaction to penicillin Medications

• OTC antacids

Family History

• Noncontributory

Social History

• Occupation: Elementary school teacher (10 years)

• Nonsmoker

• Denies illicit drug use

• Consumes wine two to three times per month •

Regular exercise

Physical Examination

• Weight: 145 lbs.; blood pressure: 128/72; pulse: 80; respiration rate: 18; temperature: 98.7 °F

• General: Calm, cooperative, in no apparent distress

• Eyes: Pupils equal, round, reactive to light

• Ears: Tympanic membranes clear

• Nares: Without nasal septal deviation; pharyngeal mucosa pink and moist

• Throat: Oropharynx without edema, erythema, tonsillar enlargement, lesions

• Abdomen: Nondistended, soft, round, nontender; normoactive bowel sounds in all quadrants

Discussion Questions

1. What are the top three differential diagnoses for PR?
2. What diagnostic tests, if any, are required for PR?
3. What pharmacological, nonpharmacological, and/or nutraceutical therapies should be prescribed for PR?
4. The results from PR’s H. pylori test returned positive. What treatment should be added to her plan of care?